The qualitative part of this meta-synthesis study was carried out in six countries (i.e., Sweden, Norway, English, Iran, Turkey, and Uganda). In total, interviews were conducted among 269 women in these 14 studies; these studies were performed using content analysis, in-depth interviews, phenomenological studies, focus group study, and combined study. (Table 1)
Table 1
Characteristics of the studies included in the meta-synthesis
Authors/year/ Country | Sample size | Age range | Research design | Data collection | Data analysis |
Karlström et al 2015/ Sweden[4] | 26 | 28–46 | Quality study | focus group | Thematic analysis |
Shahoei et al 2014/ Iran[8] | 15 | 23–29 | Quality study phenomenology | Semi-structured interviews | content analysis |
Nilsson et al 2013/Sweden[18] | 14 | - | Quality study | in-depth interviews | content analysis |
Aune et al 2015/ Norwegian [19] | 12 | 22–34 | Quality study | in-depth interviews | systematic text condensation |
Hardin et al 2004 / Birmingham’s [15] | 17 | 20–39 | qualitative descriptive study | interviews | Thematic analysis |
Dahlberg et al 2016/Norwegian [22] | 12 | 22–39 | Quality study | in-depth interviews | systematic text condensation |
Gibbins and Thomson, 2011/ England[16] | 8 | 19–37 | Quality study | unstructured interviews | phenomenological analysis |
Lundgren et al, 2004/ Sweden[14] | 10 | - | Quality study | interviews | phenomenological analysis |
Henriksen, et al,2017/ Norwegian[21] | 103 | - | mixed methods | mixed methods using comments to the questionnaire | thematic analysis |
Hosseini et al,2020/Iran[17] | 10 | 20–38 | Quality study | unstructured interviews | content analysis |
Namujju et al, 2018/Uganda[3] | 25 | 18–33 | Quality study | unstructured interviews and focus group discussions | phenomenological |
Aktas et al,2018/ Turkey[20] | 11 | 21–35 | Quality study | in-depth interviews | thematic analysis |
Hallam et a/2016/ UK[23] | 6 | 25–39 | Quality study | semi-structured interview | thematic analysis |
The meta-synthesis showed that there were two themes, four categories, and nine sub-categories. The themes include “perception” and “perspective”. Perception theme was derived from the two levels of control and security. Perspective theme was derived from of self-efficacy and self-esteem. (Table 2)
Table 2
Theme | category | Sub category | Author |
perception | control | preparation | [4, 14–17, 18] |
coping | [4, 8, 15, 17, 18, 19, 20] |
security | participation | [3, 4, 14, 15, 21–23] |
Social support | [4, 8, 18] |
Care provider support | [3, 4, 14–23], |
perspective | self-efficacy | fertility | [4, 8, 22] |
Kind of next birth | [17, 22] |
Self esteem | Self-knowledge | [4, 8, 14, 17, 22]. |
interaction | [8, 17] |
Theme 1: Perception
The positive and pleasant experience of childbirth plays a significant role in mothers’ empowerment, mother-infant bonding[6, 7], and the next maternal fertility rate[6].
The perception theme was derived from the two levels of control and security. One of the most important factors causing childbirth experience to be pleasant is preparation through information obtained from various sources, including participation in childbirth classes and acquisition of related knowledge in these classes, reading various books, journals and websites, or using advice from family members and other reliable individuals like midwives or the gynecologist. Based on the obtained knowledge, the mother recognizes that the labor pain and childbirth problems are part of the childbirth process and this preparation leads to realistic expectations. Realistic expectations have a positive effect on the satisfaction of positive experiences [4, 14–17]. In the conducted review, having confidence in the ability to give birth had resulted in a positive attitude and the feeling that labor pain and its problems are under control[4, 14, 18].
“For me, the mental training was important…it was very good. We talked a lot about expectations, which is useful not only when giving birth, and about our relation that we do this together”[4].
During childbirth, people use different approaches to confront and manage the childbirth process, including cognitive and behavioral approaches. The cognitive approach includes religious beliefs[8, 17] and focusing on contractions[4, 15, 17, 18] and mental imagery during labor[17, 19].The behavioral approach includes walking, position changing[15, 17] and relaxation and deep breathing[15, 17, 20].
“I read that I should think of a mountain top. That I had to get up and up. I was at the top of the mountain when I started to push. And then I had to get down again. And that was it!”[19]
Several qualitative studies have indicated that feeling safe and calm during labor and delivery is a key factor in having a pleasurable childbirth experience. Paying attention to the pregnant mother in decision-making and husband and care provider’s support are essential factors in making mothers feel secure and peaceful.
Seeing and listening to childbearing woman is another key factor in women's sense of security. This includes participating the mother in the delivery process and decision-making during labor and childbirth [3, 4, 14, 15, 21–23]. The presence and support of the husband and other reliable people leads to mental relaxation and a sense of safety and confidence [4, 8, 18].
“When I came back to the labour ward they told me “the baby has reached you push”, I was not feeling any energy. ….my husband helped me, held me and he never feared. When the baby was coming out, he told me that “bambi” (meaning my friend) push more, the head is coming, add in more effort. … I felt good, I liked it so much because he gave me support, and he was there”[3]
Women stated that they needed professional support in addition to medical and midwifery services. Professional support includes the presence and support of midwives through the constant presence of a midwife during delivery to guide the pregnant woman, inform her of the progression of labor, and provide other necessary information[4, 15–18, 23], The midwife's individual characteristics[3, 18, 22], allocating adequate time to the pregnant woman[18, 22], friendly behaviors, proper communication skills [14, 15, 17, 19, 21, 22], high skills and abilities [3, 14, 21–23].
“I had a very kind midwife and she had always enough time for me. I experienced that she was genuinely interested in me and my pregnancy. She remembered me…” [22]
“She was a very warm and caring person, I felt safe. She always explained what happened and what she did. Yes … I was relaxed in a way, I thought this would be just as natural as driving to the shop and buying dinner.”[22]
Theme: Perspective
After delivery, women will experience different feelings, positive and negative attitudes, as well as changes in their lives. Having positive experiences in vaginal childbirth leads to forming a positive attitude in women toward the choice of vaginal childbirth for the next pregnancy and the desire to have more children [4, 8, 22]. Reversely, negative experiences in childbirth may lead to negative attitudes and the choice of cesarean delivery for the next pregnancy and the lack of subsequent fertility.
Women stated that after having a pleasant childbirth experience, they felt empowered; in fact, they believed in their inner strength. They believed that childbirth increases their patience [8, 17], self-sufficiency [8, 14], accountability [8, 17], self-efficacy [17, 22], self-esteem [14, 17, 22] and pride [4, 17, 22].
“Giving birth is very sweet, there is no pain as sweet as labor pain and childbirth and I choose vaginal delivery again, if I want to give birth.”[17]
“I am very proud of myself because I’m a mother. I am proud that I have a baby and I am very happy. I can’t imagine myself without my baby.” [8]